discharge planning

Question 1

The IDEAL discharge plan model

Answer 1

Include family and caregivers in discharge planning
Discuss 5 key areas (describe life at home, review meds, highlight warning signs, explain test results, review follow up appts)
Educate pt and caregivers
Assess patient and caregiver understanding
Listen

Question 2

AM-PAC

Answer 2

activity-measure for post acute care

assesses functional mobility, ADLs, and cognition

higher score - greater function

Question 2

6 clicks

Answer 2

a shorter version of AM PAC that assesses moving to different positions, daily activities, and walking/steps

does not assess cognition

Question 3

AM-PAC 6 clicks: readmission predictions*

Answer 3

cut points that maximize odds of readmission were determined to be scores less than 17 for basic mobility

Question 4

PT value

Answer 4

odds for readmission were 2.3x greater among participants who did not discharge to the location with the services recommended by their PT

Question 5

red flags

Answer 5

Decreased lower extremity strength
Impaired gait speed
Decreased transfer ability
Decreased steps per day or activity levels
Decline in self-reported/observed ADLs
Significant fall history
Sudden change in health status
Sudden change in cognitive status
Poor or absent functional improvement from baseline
Lack of home support

Question 5

discharge to inpatient rehab facitility

Answer 5

must require active and ongoing intervention from at least 2 different rehab disciplines (PT, OT, SLP)

patient able and needs at least 3 hours of therapy per day 5 days/wk

Question 6

discharge to SNF

Answer 6

to qualify a pt must have a medically necessary inpatient stay for at least 3 days

patient may have up to 100 days of SNF

rehab services for 1-2 hrs per day including PT, OT, SLP

24 hr nursing care

Question 7

discharge to long term acute care hospital

Answer 7

designed for pts with advanced medical needs

most pts come from ICU

rehab services 1-3 hrs/day for 5 days/wk

average length of stay is 25 days

Question 8

discharge - palliative care

Answer 8

life threatening or chronic illness

does not depend on stage of the disease or limited lifepsan

compassionate care to provide relief of symptoms and improve QoL

many of these pts may be eligible for hospice but not ready for end of life care and want to continue curative therapies

Question 9

discharge - hospice

Answer 9

comfort care/symptom relief, no curative measures

usually when a pt has less than 6 months to live

pt must meet Medicares eligibility for coverage

goal for rehab is to maximize pts independence, education, pain management, DME or home mod.